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� <br /> J <br /> �, ,�. � ;,�+�r� �.y �'`�� C�'f 6ra �"(�tawsl 5�['. a�`aj , <br /> <��;�`"�.�,�-'���'.S��x��a��i,� 6� � .���{ r i!' .� `,D��n`.���`�,-.�-r+.r� ";���.ca_w a.u.,.t,.�.�k;�A.F,���,�t�,.�� <br /> FIXTURE BSMT 1 2 OTHER FIXTURE BSMT 1 2 OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet / Floor Drains <br /> Lavatory � Sewer Ejector <br /> Bathtub / Laundry Tray <br /> Shower � Washer <br /> Kitchen Sink Water Heater <br /> Disposal Water Softener <br /> Dishwasher Wet Baz <br /> Sillcocks Miscellaneous <br /> +�� g q � �/� gn <br /> �" " � p i?9,����i9kTax 'E. � �G"� <br /> � � �p � � .,�� � €' <br /> �.�� '�t��ax _ .3a6 w ���. <br /> ❑ Yes,this section applies <br /> The replacement of a Residenrial fixture or appliance that meets all three of the following requirements: <br /> 1. Does not require modification to electrical or gas service. <br /> 2. Has a total cost of$500.00 or less;excludin�the cost of the fixture or appliance:and <br /> 3. Is improved,installed or replaced by the homeowner or licensed contractor. <br /> Skip next section,if this applies; Cost of Permit $ 15.00 <br /> State Surcharge $ .50 <br /> Mail-In Fee(If Applicable) $ 1.50 <br /> Total Permit Fee $ <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />